Director’s Note: The field of restorative reproductive medicine (RRM) continues to evolve, as we recognize the interconnectedness of the various systems in the human body. During Crohn’s & Colitis Awareness Week, former FACTS elective student Emilie Burruss summarizes a review article by Martin et al [1] on the relationship between inflammatory bowel disease (IBD) and female fertility. Burruss expands on the topic by noting the role of charting the female cycle to restore reproductive health and discussing ways fertility awareness-based methods (FABMs) fill a significant gap in family planning for countless patients with IBD. Some of these women may also benefit from RRM interventions such as low-dose naltrexone (LDN) to ameliorate inflammation and improve fertility outcomes. Join FACTS to gain access to more information on this topic, including Dr. Boyle’s lecture on LDN, free to members!

Inflammatory Bowel Disease and Fertility

In the article, “Fertility and Contraception in Women with Inflammatory Bowel Disease,” the authors addressed the question of why, despite essentially normal fertility, women with inflammatory bowel disease (IBD) tend to have fewer children. [1] They explained the pathophysiology of IBD and discussed research showing these women may have lower fertility rates due to the dyspareunia, decreased libido, malnutrition, and anemia that often accompany severe active flares. [1] Additionally, women with IBD in need of surgery may require deep pelvic dissection, which can lead to pelvic adhesions and tubal factor infertility. [1] Even women treated with medications shown to have no effect on fertility have family planning concerns, perhaps due to sexual dysfunction, body image, impact of disease on relationships, and concern about effects of the condition or its treatment on progeny. The article by Martin et al shines light on an opportunity for fertility awareness-based methods (FABMs) to reduce fertility concerns and restore reproductive health in women with IBD.

“The authors addressed the question of why, despite essentially normal fertility, women with inflammatory bowel disease (IBD) tend to have fewer children.  They explained … (it may be) due to the dyspareunia, decreased libido, malnutrition, and anemia that often accompany severe active flares.”

Despite the varying concerns related to their fertility and family planning, the authors noted 68% of women with IBD had never discussed their concerns with a physician. [1] According to the American College of Obstetrics and Gynecologists (ACOG), women with lower gastrointestinal tract disorders who discuss their fertility concerns with a medical professional are most likely to do so with their Ob/Gyn physician compared to other specialties. [2] Therefore, it is important that both patients and physicians initiate these conversations to debunk misconceptions related to their fertility and discuss the true risks they are facing.

Concerns vs. True Risks

These patients have many valid concerns. For instance, compared to patients in remission, women in an active flare of IBD have a higher risk of preterm birth, low birth weight, and small-for-gestational-age infants. [1] For this reason, it is important to work toward a goal of remission before attempting to conceive. On the other hand, studies show that for women not seeking pregnancy, those with IBD were over 50% less likely to have been prescribed any form of contraception by a physician. [1] Several studies found that women with IBD can have more diarrhea and abdominal pain during menses, with symptomatic improvement in such cyclical IBD symptoms reported by 19% of estrogen-based contraceptive users and 47% of levonorgestrel IUD users. [1]

“Women in an active flare of IBD have a higher risk of preterm birth, low birth weight, and small-for-gestational-age infants.”

The Value of Individualized Care

While some forms of contraception may be less desirable in certain patients with IBD, individualized conversations may increase adherence to their method of choice. [1] For instance, patients at risk for malabsorption may want to avoid oral combined contraceptives, while those at risk for osteopenia should likely avoid medroxyprogesterone acetate injections. [1] Yet, the authors do not list these as contraindications for all patients with IBD and add that all methods are available to these patients, with the preferred method determined by individual choice. Fertility awareness-based methods (FABMs) are certainly valid choices for these patients, with the added benefit of no restrictions or potential adverse effects on the mother or her child.

Education Adds Healthier Choices

As discussed throughout the FACTS course, a woman who understands her body, her cycle, and the changes that will occur over time is equipped with knowledge to make healthier choices. A patient with IBD can use FABMs to learn about her reproductive health by tracking and interpreting her physical signs, such as basal body temperature and cervical fluid secretions, as extra vital signs denoting differences she sees in herself versus a patient without IBD. [3]This could instill confidence in her fertility goals or urge her to see a physician to ask questions about her family planning desires. When patients decide to bring their concerns to a physician, the physician needs to be well informed regarding FABMs. As Dr. Adedamola Badewa noted in her summary of research titled, “Patient-Centered Care in Contraceptive Counseling,” “although women favor autonomy in decision making during counseling, they also desire the clinician’s involvement in their decision-making process.” [4] Physicians’ role in educating themselves about the fertility concerns of these patients and the different methods available to them is essential to provide comprehensive care.

Some Benefits of FABMs

By delving into this topic through the FACTS elective, participants learn of the wide range of methods many patients prefer for family planning beyond the traditional approach. A woman with IBD can chart her cycle and symptoms, and with guidance from a physician trained in FABMs, she can learn to distinguish concomitant premenstrual syndrome (PMS) or endometriosis pain from IBD flares. In the absence of outlying symptoms, charting her cycle can instill confidence in her reproductive abilities despite her disease course. Furthermore, for women with autoimmune conditions such as IBD, it may be difficult to avoid medications and interventions. FABMs can give patients who desire a more organic approach a different choice to avoid or delay certain interventions. FABMs can educate these patients about their reproductive health and enable them to meet their reproductive goals.

“A woman with IBD can chart her cycle and symptoms, and with guidance from a physician trained in FABMs, she can learn to distinguish concomitant premenstrual syndrome (PMS) or endometriosis pain from IBD flares.”

Final Thoughts

Future research is needed to further explore the role of specific FABMs in this population and add to their confidence and adherence when using these methods. Other research topics could focus on cervical mucus patterns in these patients, how coexisting autoimmune disorders such as thyroid dysregulation affect their family planning goals, and the role of dyspareunia related to IBD versus concomitant conditions such as endometriosis.

This article’s [1] relevance to the field of fertility awareness and restorative reproductive medicine is abundant. Understanding the concerns of women with IBD highlights the need to educate medical professionals about these patients’ broader choices for family planning depending on their specific disease course. Charting her cycle provides an extra vital sign to help a woman understand her symptoms and grow in confidence in her unique reproductive goals. While more research is needed on this topic, women can be assured that FABMs remain a reliable option for them regardless of their disease.

Editor’s Note: Table 2 of the article by Martin et al [1] compares the efficacy of contraceptive methods and lists special considerations for patients with IBD. Although FABMs are included among the methods (“fertility awareness”), the table cites 24% as the rate of unintended pregnancy after 1 year of typical use, which is incorrect. This bloated percentage results from lumping together the various FABMs, but the data demonstrates much lower rates of unintended pregnancy (as low as 2%) for individual FABMs. The CDC published a correction of this often-cited mistaken percentage after Martin et al published their article in 2016.